PassPoint HESI questions

The nurse prepares to give penicillin to a client with osteomyelitis. The healthcare provider has ordered 700 mg IM. The vial is a mix-o-vial containing drug powder and sterile water for injection. When mixed together the vial contains 1 g/3.4 ml. How much should the nurse draw up to give this client? Record your answer using one decimal place. _______ mL

2.4 mL X = (Dose Desired)/(Dose on Hand or Dose Available) × milliliters/grams X =(700 mg)/1000 × (3.4 ml)/(1 g)=2.4 ml

A client is suspected of having carpal tunnel syndrome. The nurse assesses for Tinel's sign. Identify the area where the nurse would percuss in an attempt to elicit Tinel's sign.

Explanation: Carpal tunnel syndrome is compression of the median nerve in the wrist that supplies feeling and movement to parts of the hand. Tinel's sign may be used to help identify carpal tunnel syndrome. It is elicited by percussing lightly over the median nerve, located on the inner aspect of the wrist. If the client reports tingling, numbness, and pain, the test is considered positive.

Which question is most important for a nurse to ask when taking a history from a client diagnosed with tinea corporis? a)"Do you have any pets?" b)"Have you recently consumed alcohol?" c)"What is your occupation?" d)"How has this affected you?"

a)"Do you have any pets?" Explanation: An infected pet may be the source of this infection. The other questions are appropriate to ask when obtaining a health history related to skin disorders but are not the priority question.

A client who is to have a vaginal radium implant tells the nurse she is concerned about being radioactive. The nurse should tell the client: a)"The radioactive material is controlled and stays with the source; once the material is removed, no radioactivity will remain." b)"The radioactivity will gradually decrease, and you will be discharged when the radioactive material reaches its half-life." c)"The radiation is necessary to treat your tumor." d)"Careful shielding prevents the area above your waist from radioactivity."

a)"The radioactive material is controlled and stays with the source; once the material is removed, no radioactivity will remain." Explanation: The radioactivity comes from a radioactive material such as radium or cesium. Radioactivity affects tissues but does not make them radioactive. Once the radioactive source is removed, no radioactivity remains. Accurate information can help alleviate ungrounded fears.The time required for a radioactive substance to be half-dissipated is called its half-life, but this does not determine discharge time. The client receiving sealed internal radiotherapy is not discharged until the radioactive source is removed.While the radiation is necessary for treatment, telling the client this does not provide information to address her concerns.With cervical implants, there is no way to shield the area above the waist from radiation.

As two toddlers play side by side, their parents note that they are not sharing their toys with each other and one cries when a toy is taken by the other child. The nurse hears the parents telling their children to share. Which is the nurse's best response? a)Do nothing as this is normal behavior for a toddler. b)Encourage the parents to teach their children to share. c)Separate the children so that they cannot fight. d)Sit between the children and encourage them to play together.

a)Do nothing as this is normal behavior for a toddler. Explanation: Toddlers participate in parallel play. They play beside each other but not together. They are not ready to "share" their toys. No intervention is needed for this normal developmental behavior

A client experienced a pelvic fracture in a motor vehicle collision several months ago. Recovery has been slow. Among the challenges presented by this event is that sexual activity causes a dull ache in the pelvis. What client problem is the priority? a)pain b)depression c)sexual dysfunction d)self-consciousness

a)pain Explanation: The client's change in sexual behavior is directly attributable to the pain from the injury. There is no evidence of depression, sexual dysfunction, or self consciousness.

A client is to use an insulin pen. Which action indicates the client is using the pen correctly? Select all that apply. a)stores the unopened pens in the refrigerator b)injects the insulin in sites around the abdomen c)primes the pen by expelling any air d)massages the site after injection e)saves needle for reuse

a)stores the unopened pens in the refrigerator b)injects the insulin in sites around the abdomen c)primes the pen by expelling any air Explanation: Insulin pens should be stored in the refrigerator before use; once opened they can be stored at a cool room temperature. The pen needs to be primed by expelling air before injecting the insulin. After the injection, the site can be patted, but not massaged. Needles cannot be reused; the client should remove the needle and place in a hard plastic container for disposal.

The nurse is counseling a client regarding treatment of the client's newly diagnosed depression. The nurse emphasizes that full benefit from antidepressant therapy usually takes how long? a)1 week b)2 to 4 weeks c)5 to 7 weeks d)8 weeks

b)2 to 4 weeks Explanation: Full benefit from an antidepressant medication usually takes about 2 to 4 weeks on an adequate dose.

A client is in balanced suspension traction to maintain alignment of a fractured tibia. Which activities are safe for the client? a)Eat while lying flat. b)Raise the hips using trapeze. c)Rotate side to side. d)Flex and extend the ankle on affected side.

b)Raise the hips using trapeze. Explanation: The client in balanced suspension traction can raise the hips using a trapeze. The client can then use the bedpan. The client can be in a sitting position to eat. The client should not move side to side but can turn toward the affected side. The client should not flex or extend the ankle on the affected side.

In which areas of the United States and Canada is the incidence of tuberculosis highest? a)rural farming areas b)inner-city areas c)areas where clean water standards are low d)suburban areas with significant industrial pollution

b)inner-city areas

When teaching the family of an older infant who has had a spica cast applied for developmental dysplasia of the hip, which information should the nurse include when describing the abduction stabilizer bar? a)It can be adjusted to a position of comfort. b)It is used to lift the child. c)It adds strength to the cast. d)It is necessary to turn the child.

c)it adds strength to the cast Explanation: The abduction bar is incorporated into the cast to increase the cast's strength and maintain the legs in alignment. The bar cannot be removed or adjusted, unless the cast is removed and a new cast is applied. The bar should never be used to lift or turn the client because doing so may weaken the cast.

A nurse is preparing a client for bronchoscopy. Which instruction is appropriate for the nurse to give to the client? a)"You will need to stay flat after the procedure." b)"Don't cough after the procedure." c)"You will not be able to talk for 4 hours following the procedure." d)"Don't eat for 6 hours prior to the procedure."

d)"Don't eat for 6 hours prior to the procedure." Explanation: Bronchoscopy involves visualization of the trachea and bronchial tree. To prevent aspiration of stomach contents into the lungs, the nurse should instruct the client not to eat or drink anything for approximately 6 hours before the procedure. The client will need to be in a semi-Fowler's position after the procedure. It isn't necessary for the client to avoid talking or coughing.

A client has renal colic due to renal lithiasis. What is the nurse's first priority in managing care for this client? a)Do not allow the client to ingest fluids. b)Encourage the client to drink at least 500 mL of water each hour. c)Request the central supply department to send supplies for straining urine. d)Administer an opioid analgesic as prescribed.

d)Administer an opioid analgesic as prescribed. Explanation: If infection or blockage caused by calculi is present, a client can experience sudden severe pain in the flank area, known as renal colic. Pain from a kidney stone is considered an emergency situation and requires analgesic intervention. Withholding fluids will make urine more concentrated and stones more difficult to pass naturally. Forcing large quantities of fluid may cause hydronephrosis if urine is prevented from flowing past calculi. Straining urine for small stones is important, but does not take priority over pain management.

A client asks the nurse to explain the meaning of her abnormal Papanicolaou (Pap) smear result of atypical squamous cells. The nurse should tell the client that an atypical Pap smear means that what has occurred? a)Abnormal viral cells were found in the smear. b)Cancer cells were found in the smear. c)The Pap smear alone is not very important diagnostically because there are many false-positive results. d)The cells could cause various conditions and help identify a problem early.

d)The cells could cause various conditions and help identify a problem early. Explanation: The Pap smear identifies atypical cervical cells that may be present for various reasons. Cancer is the most common possible reason, but not the only one. The Pap smear does not show abnormal viral cells unless specific gene typing is done for human papillomavirus. An adequate smear provides accurate diagnostic data; the false-positive rate is only about 5%.

A 7-year-old client is prescribed a clear liquid diet by the healthcare provider after tonsillectomy. What nutrition will the nurse give the child? Select all that apply. a)cream of chicken soup b)orange juice c)ice cream d)apple juice e)lime gelatin f)chicken broth

d)apple juice e)lime gelatin f)chicken broth Explanation: Clear liquids include clear broth, gelatin, clear juices, water, and ice chips. The client can see through clear liquids. Cream of chicken soup, orange juice, and ice cream are not clear liquids. They are included in a full liquid diet because the cream soup and ice cream have milk products and the orange juice has pulp.

A 10-year-old child is taking high doses of aspirin. Which finding indicates the child is experiencing early salicylate toxicity? a)chest pain b)pink-colored urine c)slowed pulse rate d)dizziness

d)dizziness Explanation: Signs and symptoms of early salicylate toxicity include tinnitus, disturbances in hearing and vision, and dizziness. Salicylate toxicity may cause nausea, vomiting, diarrhea, and bleeding from mucous membranes from long-term use.Pink-colored urine, a slowed pulse rate, and chest pain, rarely occurring in children, are not associated with salicylate toxicity.

A nurse should encourage a client with a wound to consume foods high in vitamin C because this vitamin a)restores the inflammatory response. b)enhances oxygen transport to tissues. c)reduces edema. d)enhances protein synthesis.

d)enhances protein synthesis. Explanation: The client should be encouraged to consume foods high in vitamin C because vitamin C is essential for protein synthesis, an important part of wound healing. Hemostasis is responsible for the inflammatory response and reducing edema. Hemoglobin is responsible for oxygen transport.

A client has had an hypophysectomy. What signs of a potential complication should the nurse teach the client to report? a)acromegaly b)Cushing's disease c)diabetes mellitus d)hypopituitarism

d)hypopituitarism Explanation: Most clients who undergo adenoma removal experience a gradual return of normal pituitary secretion and do not experience complications. However, hypopituitarism can cause growth hormone, gonadotropin, thyroid-stimulating hormone, and adrenocorticotropic hormone deficits. The client should be taught to monitor for change in mental status, energy level, muscle strength, and cognitive function. In adults, changes in sexual function, impotence, or decreased libido should be reported. Acromegaly and Cushing's disease are conditions of hypersecretion. Diabetes mellitus is related to the function of the pancreas and is not directly related to the function of the pituitary.

A young female client is receiving chemotherapy and mentions to the nurse that she and her husband are using a diaphragm for birth control. Which information is most important for the nurse to discuss? a)inconvenience of the diaphragm b)transmission of sexually transmitted diseases c)body changes related to hormones d)infection control

d)infection control Explanation: The risk of becoming neutropenic during chemotherapy is very high. Therefore, an inserted foreign object such as a diaphragm may be a nidus for infection. Although the nurse may wish to inform the client about the ease with which various contraceptive modalities may be used, the focus of this discussion should be on preventing an infection, which can be fatal for the neutropenic client. There are no data to suggest the client is at risk for acquiring a sexually transmitted disease. The client will not be experiencing body changes directly related to hormonal changes.

Commercial formulas contain 20 calories per 30 mL. A 1-day-old infant was fed 45 mL at 0200, 0530, 0800, 1100, 1400, 1630, 2000, and 2230. What is the total amount of calories the infant received today? Record your answer using a whole number.

240 calories Explanation: Eight feedings x 45 mL per feeding equals 360 mL. 360 mL x 20cal/30 mL = 240 calories.

A client is admitted for suspected GI disease. Assessment data reveal muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendency. The nurse suspects the client has a)cirrhosis. b)peptic ulcer disease. c)appendicitis. d)cholelithiasis.

a)cirrhosis. Explanation: Muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendencies are all symptoms of cirrhosis. The client may also have mild fever, edema, abdominal pain, and an enlarged liver. Clients with peptic ulcer disease complain of a dull, gnawing epigastric pain that's relieved by eating. Appendicitis is characterized by a periumbilical pain that moves to the right lower quadrant and rebound tenderness. Cholelithiasis is characterized by severe abdominal pain that presents several hours after a large meal.

Which action by the nursing assistant would require immediate intervention by the nurse? a)restraining a school-age child at risk for self-harm because the nursing assistant had to leave the room b)assisting a preschool-age child in the bathroom with the door closed c)transporting a newborn in a bassinet from the mother's room to the newborn nursery d)removing a toddler from a sleeping mother's bed to the crib

a)restraining a school-age child at risk for self-harm because the nursing assistant had to leave the room Explanation: The nurse supervising a nursing assistant will need to intervene when a nursing assistant restrains a client requiring one-on-one observation to leave the room. It should be reinforced with the nursing assistant to call for a replacement for the time needed to leave the client. Assisting a preschooler in a bathroom is appropriate for that age group. Transporting an infant in a bassinet is appropriate and within the scope of the nursing assistant's job. Removing the toddler from the mother's bed to the crib is appropriate. Cosleeping is dangerous for the child, and the mother should be educated on the risks.

The RN is administering intravenous chemotherapy to a client with cancer. Which precautions are necessary when administering chemotherapy? Select all that apply. a)taping all IV tubing connections b)wearing gloves when handling the client's urine c)disposing of chemotherapy waste as hazardous material d)wearing a long-sleeved gown when administering chemotherapy

b)wearing gloves when handling the client's urine c)disposing of chemotherapy waste as hazardous material Explanation: Nurses preparing and administering chemotherapy wear gloves and a disposable, long-sleeved gown. Antineoplastic agents are disposed of as hazardous material and gloves are always worn when handling the excretions of clients who have received chemotherapy. It is not appropriate to tape IV tubing connections; antineoplastic agents are administered using Luer lock fittings on all intravenous tubing to minimize the risk of exposure from needle stick injury.

Which discharge instruction should a nurse give a client who's had surgery to repair a hip fracture? a)"Don't flex your hip more than 30 degrees, don't cross your legs, and have someone help you put your shoes on." b)"Don't flex your hip more than 60 degrees, don't cross your legs, and have someone help you put your shoes on." c)"Don't flex your hip more than 90 degrees, don't cross your legs, and have someone help you put your shoes on." d)"Don't flex your hip more than 120 degrees, don't cross your legs, and have someone help you put your shoes on."

c)"Don't flex your hip more than 90 degrees, don't cross your legs, and have someone help you put your shoes on." Explanation: Falls in the home cause most injuries among the elderly. Elderly clients should take measures to decrease the clutter that can contribute to falls, such as removing objects such as throw rugs from the floor. Elderly clients should also install grab bars in the shower and next to the toilet. The threat of fire makes burglar bars on every window impractical.

Which baseline laboratory data should be established before a client is started on tissue plasminogen activator or alteplase recombinant? a)potassium level b)lee-White clotting time c)hemoglobin level, hematocrit, and platelet count d)blood glucose level

c)hemoglobin level, hematocrit, and platelet count Explanation: The baseline laboratory data that are established before a client is started on tissue plasminogen activator or alteplase recombinant include hematocrit, hemoglobin level, and platelet count.

On reviewing a child's laboratory results, the nurse notes a serum potassium level of 3.3. What should the nurse encourage the child to drink? a)cranberry juice b)apple juice c)grape juice d)orange juice

d)orange juice Explanation: A serum potassium level of 3.3 is low for a child; the normal range is 3.5 to 5.0. Orange juice is an excellent source of potassium, and the nurse should encourage its consumption. Additional sources of potassium are bananas, cantaloupe, grapefruit juice, tomato juice, honeydew melon, nectarines, and boiled or baked potatoes.Cranberry juice, apple juice, and grape juice all contain less potassium than orange juice does.

Three hours postpartum, a primiparous client's fundus is firm and midline. On perineal inspection, the nurse observes a small, constant trickle of blood. Which condition should the nurse assess further? a)retained placental tissue b)uterine inversion c)bladder distention d)perineal lacerations

d)perineal lacerations Explanation: A small, constant trickle of blood and a firm fundus are usually indicative of a vaginal tear or cervical laceration. If the client had retained placental tissue, the fundus would fail to contract fully (uterine atony), exhibiting as a soft or boggy fundus. Also, vaginal bleeding would be evident. Uterine inversion occurs when the uterus is displaced outside of the vagina and is obvious on inspection. Bladder distention may result in uterine atony because the pressure of the bladder displaces the fundus, preventing it from fully contracting. In this case the fundus would be soft, possibly boggy, and displaced from midline.

The nurse is caring for a client who has a prescription for antiembolism stockings. The client is confused and begins kicking at the nurse during the measurement of the client's legs. What is the next action by the nurse? a)Ask an unlicensed assistive personnel to assist with the application of the antiembolism stockings. b)Administer prescribed lorazepam 1 mg by mouth. c)Contact the health care provider to make aware that the antiembolism stockings cannot be applied. d)Place the antiembolism stockings without measuring the client's legs.

a)Ask an unlicensed assistive personnel to assist with the application of the antiembolism stockings. Explanation: When a client is confused and is kicking at the nurse, the next action would be to ask a nursing assistant to assist with stabilizing the legs for the application of the stockings. Medicating the client with ordered lorazepam would only be done after attempting the application with additional assistance. Contacting the health care provider would be done after all options for the application of the stockings had been attempted. It is important to have the correct size antiembolism stocking; therefore, the client's legs would need to be measured before applying the stockings.

A client in a wheelchair comes to the clinic for a follow-up evaluation of pressure ulcers on the buttocks. The client reports that the family has been changing the hydrocolloid dressings every 3 to 5 days. During the past few weeks, the client has been spending less time in the wheelchair and, when in the wheelchair, uses a cushion. During the appointment the nurse notes that the client is not using a cushion, and that the wound is covered with a dry sterile dressing. How should the nurse initially approach the client about the treatment regimen? a)Ask the client to explain the treatment regimen. b)Call the family contact to ask about how the treatments have been done. c)Explain pressure ulcer development in terms that the client understands. d)Provide a brief anatomy and physiology lesson on how pressure ulcers develop.

a)Ask the client to explain the treatment regimen. Explanation: It is important to first assess what the client knows about the treatment regimen. The nurse should then provide further teaching in terms that the client understands; this should be done after an assessment of what the client knows. The client should be using a cushion to sit on to reduce pressure, and the wound should be kept moist to promote healing. Care decisions can be made by the client; however, the nurse must ensure that the client has available knowledge to make an informed decision. Calling the family may be an option, but the client should be the first one to explore what is known about the treatment. Providing an in-depth explanation about the anatomy and physiology of pressure ulcer development is not necessary.

The nurse is verifying the identity of a client prior to administering medication. The client has had a stroke and has ataxia. What is the best action by the nurse? a)Ask the client to state name and birthdate. b)Give client paper and pencil with which to write name and birthdate. c)Recall the client's facial features to verify the client's identity. d)Ask two staff members to state the name of the client in the room.

a)Ask the client to state name and birthdate. Explanation: The nurse should ask the client to state name and birthdate and compare it to the client's records. The nurse does not need to provide a pencil and paper for the client to write his or her name and birthdate as a client has ataxia, not apraxia. Ataxia involves muscle movement, typically in the arms and legs. Apraxia involves speech. Recalling the client's facial features to verify identity is prone to errors. Asking two staff members which client is in the room does not verify identity.

When an epidural catheter is used for postoperative pain management, what should the nurse do? a)Assess but not disturb the epidural dressing. b)Change the epidural dressing daily. c)Change the epidural dressing daily only if it is wet. d)Use strict aseptic technique when handling the epidural catheter.

a)Assess but not disturb the epidural dressing Explanation: The nurse should assess but not disturb the epidural dressing because the catheter can be easily dislodged and organisms can easily be transmitted into the central nervous system. The nurse should not have to change the dressing at all if a waterproof dressing is applied over the epidural site. Even with strict aseptic technique, a drain into a sterile cavity is a direct route for transmission of organisms and places a client at increased risk of infection, and the nurse should not handle the dressing or the catheter.

A client who is admitted to the adult unit of a mental health care facility with depression tells the nurse that he has pedophilia. What should the nurse do? a)Be aware of personal opinions and views. b)Recognize that because the client is depressed, the client will not be able to discuss the pedophilia. c)Ensure that the client is never alone with other clients on the unit. d)Refer the client to group therapy.

a)Be aware of personal opinions and views. Explanation: The nurse must be aware of personal opinions and views when caring for clients with psychosexual disorders. The care plan for the client will be developed to manage both the depression and the pedophilia. It is not necessary to restrict the client's interactions with others on this adult mental health unit. The health care provider (HCP) will determine the type of therapy that will be most appropriate for this client.

A nurse is caring for a preschooler who sustained deep partial-thickness burns on the hands as a result of touching a hot pot on the stove. What is most important for the nurse to consider in discharge teaching? a)Include the child in the teaching process. b)Provide teaching to the parents in the treatment room. c)Ask the child to verbalize why the accident occurred. d)Delay the teaching until both parents are present.

a)Include the child in the teaching process. Explanation: The nurse should include the preschooler in any discharge teaching performed. Preschoolers have developed reasoning skills and are beginning to understand the concepts of right and wrong and cause and effect, but verbalizing the reason for the accident is not the most important focus. It isn't necessary for both parents to be present during teaching, although it is desirable.

The registered nurse (RN) is teamed with a licensed practical/vocational nurse (LPN/VN) in caring for a group of cardiac clients on a pediatric unit. Which action by the LPN/VN indicates the nurse should intervene immediately? a)The LPN/VN assists a child to the bathroom 2 hours after a cardiac catheterization. b)The LPN/VN places an infant having a cyanotic episode in a knee-chest position. c)The LPN/VN checks a child's apical heart rate prior to administering digoxin. d)The LPN/VN brings breakfast to a child who is scheduled for an electrocardiogram.

a)The LPN/VN assists a child to the bathroom 2 hours after a cardiac catheterization. Explanation: Because the femoral artery is usually used as the access site during a cardiac catheterization, children are required to remain on bed rest (with the head only slightly elevated) for several hours after the procedure to avoid arterial bleeding at the site. A knee chest position is the correct position for an infant during a cyanotic episode as it will create peripheral resistance to the extremities, shunting blood to the heart. The apical heart rate is assessed prior to administering this medication; administration can be performed by an experienced LPN/VN, although medication is checked with the RN prior to administration. Because echocardiography is noninvasive, there is no need to withhold meals before this procedure.

The nurse is evaluating infection control practices performed by a spouse on a loved one who has methicillin resistant Staphylococcus aureus (MRSA) in a right leg wound. Which actions indicate that the spouse requires further teaching? Select all that apply. a)The spouse places soiled dressing supplies in the kitchen garbage can. b)Disinfectant spray is used on the table where dressing supplies are prepared. c)Clean gloves are used for wound dressing removal. d)Sheets with wound drainage are washed in lukewarm water. e)Dressing supplies are placed in a clean, dry location. f)Routine hand hygiene is performed before and after care.

a)The spouse places soiled dressing supplies in the kitchen garbage can. d)Sheets with wound drainage are washed in lukewarm water. Explanation: Methicillin resistant Staphylococcus aureus (MRSA) is a bacterium that causes infections in different parts of the body and is resistant to some commonly used antibiotics. Infection control practices prevent the spread of the infection. Further teaching is needed if a nurse notes that soiled dressing supplies are placed in a community garbage can such as one located in the kitchen. Soiled sheets need to be wash in hot water and dried in a clothes dryer. It is correct to clean and disinfect the area where dressing supplies are prepared. Routine hand hygiene followed by wearing clean gloves is appropriate when removing the dressing. Sterile gloves may be needed when completing

Which of the following arterial blood gas (ABG) results would the nurse anticipate for a client with a 3-day history of vomiting? a)pH: 7.55, PaCO2: 60 mm Hg, HCO3-: 28 b)pH: 7.45, PaCO2: 32 mm Hg, HCO3-: 21 c)pH: 7.28, PaCO2: 25 mm Hg, HCO3: 15 d)pH: 7.34, PaCO2: 60 mm Hg, HCO3: 34

a)pH: 7.55, PaCO2: 60 mm Hg, HCO3-: 28 Explanation: The client's ABG would likely demonstrate metabolic alkalosis. Metabolic alkalosis is a clinical disturbance characterized by a high pH (decreased H+ concentration) and a high plasma bicarbonate concentration. It can be produced by a gain of bicarbonate or a loss of H+. A common cause of metabolic alkalosis is vomiting or gastric suction with loss of hydrogen and chloride ions. The disorder also occurs in pyloric stenosis where only gastric fluid is lost. The other results do not represent metabolic alkalosis.

The nurse is making rounds and observes a client who is unconscious (see figure). The unlicensed assistive personnel (UAP) has just turned the client from lying on her back and raised the side rail next to the bedside stand. Before raising the side rail on the opposite side, the nurse should: a)elevate the head of the bed to 30 degrees. b)ask the UAP to add a pillow under the right arm. c)inspect the skin at pressure points from the back-lying position. d)assistthe UAP in moving the client closer to the head of the bed.

c)inspect the skin at pressure points from the back-lying position. Explanation: The client is positioned correctly in the side-lying position. The pillows support the client's joints and do not cause unnecessary pressure on the joints or skin. It is not necessary to add another pillow under the arm or to elevate the head of the bed. The nurse should assess the client's skin for signs of breakdown, particularly at the elbows, back, hips, and heels where there were pressure points from the position in which the client was previously lying.

A client with renal failure is undergoing continuous ambulatory peritoneal dialysis. Which nursing diagnosis is the most appropriate for this client? a)impaired urinary elimination b)toileting self-care deficit c)risk for infection d)activity intolerance

c)risk for infection Explanation: The peritoneal dialysis catheter and regular exchanges of the dialysis bag provide a direct portal for bacteria to enter the body. If the client experiences repeated peritoneal infections, continuous ambulatory peritoneal dialysis may no longer be effective in clearing waste products. Impaired urinary elimination, toileting self-care deficit, and activity intolerance may be pertinent but are secondary to the risk of infection.

A neonate with heart failure is being discharged home. When teaching the parents about the neonate's nutritional needs, what should the nurse explain? a)Fluids must be restricted. b)Decreased activity level should reduce the need for additional calories. c)The formula should be low in sodium. d)The neonate may need a more calorie-dense formula.

d)The neonate may need a more calorie-dense formula. Explanation: Neonates with heart failure may need calorie-dense formula to provide extra calories for growth. Fluids should not be restricted because the nutritional requirements are based on calories per ounce of formula. Decreasing fluid intake will decrease calories needed for growth. These neonates may have limited energy due to their heart condition but have a high caloric need to stimulate proper growth and development. The sodium level should be at a normal level to ensure adequate fluid and electrolyte balance unless prescribed by the health care provider (HCP) .

A client with a history of heroin addiction is admitted to the hospital intensive care unit with a diagnosis of opioid drug overdose. While talking with a nurse, the client's parent reports a plan to his child declared legally incompetent. Which response by the nurse is most therapeutic? a)"Your child is ill and can't make decisions about health care and safety right now, but this situation is temporary." b)"You don't have the right to declare your child incompetent. Your child has rights, too." c)"I'll help you contact the hospital legal representative for help with the paperwork." d)"If you become the guardian, you'll be responsible for your child's finances and paying for treatment."

a)"Your child is ill and can't make decisions about health care and safety right now, but this situation is temporary." Explanation: The client is temporarily unable to make decisions about health care and safety. After receiving emergency care and treatment, the client will probably be able to safely manage daily affairs. The nurse's reference to the client's constitutional rights isn't a therapeutic response. It's antagonistic to the parent's concern and could be a barrier to further nurse-parent interactions. The nurse shouldn't offer to help the client's parent contact the hospital's legal representative; a hospital's legal resources wouldn't be used to help a parent petition a court to declare a client incompetent. A guardian is responsible for making decisions about an individual's welfare and protecting civil rights. A guardian doesn't assume financial responsibility.

A registered nurse (RN) has been paired with a licensed practical nurse (LPN) for the shift. Whose care should the RN delegate to the LPN? a)a 2-year-old child who nearly drowned 2 days earlier b)a 19-month-old infant who had surgery for a fractured tibia 12 hours ago c)a 6-month-old infant who has gastroenteritis and vomits every 30 minutes d)a 17-month-old infant who lost consciousness 2 hours earlier because of a head injury

a)a 2-year-old child who nearly drowned 2 days earlier Explanation: The nurse can delegate care of the near-drowning victim to an LPN. Children recover quite quickly from near-drowning experiences; acute care isn't necessary. The infant who has undergone surgery is still under the effects of anesthesia and requires close observation for dehydration, pain, and signs of adverse reactions. The infant with gastroenteritis also requires close monitoring for signs of dehydration. The infant who lost consciousness will need to be monitored most closely. The child's status could quickly become very critical.

Which client should the nurse assess first? a)a client being treated for chronic stable angina who reports a recent increase in chest pain frequency b)a client with type 2 diabetes requesting medication refills whose A1C level is 5 mg/dL c)a client being treated for right side heart failure who has 1+ pitting edema to lower extremities bilaterally and reports a 2 lb (0.9 kg) weight gain in the last week d)a client with chronic hypertension whose blood pressure today is 182/98 mm Hg

a)a client being treated for chronic stable angina who reports a recent increase in chest pain frequency Explanation: A report of increasing frequency of chest pain suggests that the client may have developed unstable angina that can lead to an acute coronary syndrome. It requires additional testing and immediate assessment. The diabetic client's A1C level is within normal limits. Pitting edema and weight gain are expected findings with right side heart failure exacerbations—this client is not unstable. The hypertensive client is not in any acute distress.

The charge nurse on the adolescent unit must decide which nurse should admit a new client. Based on the present client care assignments, who is the best candidate to admit the client? a)a nurse who was reassigned from another ward at the beginning of the shift b)a nurse whose patient with asthma has decreasing oxygen saturation levels c)a nurse caring for a client who is paralyzed and has no visiting family d)a nurse who is about to start a complicated wet-to-damp dressing change

a)a nurse who was reassigned from another ward at the beginning of the shift Explanation: The nurse's work load would be low because she was reassigned to the ward at the beginning of the shift. The client with asthma requires constant monitoring by the nurse until the situation is resolved. Simple tasks and procedures are commonly more time-consuming when clients with paralysis are involved because these clients can't directly aid in their own care. Additional time must also be allotted for the nurse about to undertake a complicated procedure, such as a wet-to-damp dressing change

A nurse is assessing the family of an infant and observes that the parents are argumentative and appear fatigued. They indicate that the baby is not breastfeeding well and cries through the night. What would be the nurse's priority nursing diagnosis for this infant? a)altered nutrition (less than body requirements) related to difficulty sucking b)parental sleep pattern disturbance related to the baby's feeding schedule c)knowledge deficit related to normal infant growth and development d)altered role performance related to new responsibilities within the family

a)altered nutrition (less than body requirements) related to difficulty sucking Explanation: The nurse's initial priority should be to address the caloric intake of the baby through health teaching and support of the parents to ensure that the baby will meet age-appropriate growth and development milestones.

A nurse caring for a child notes that the child begins to experience decreased urinary output, drop in blood pressure, and rapid thready pulse. Which is the appropriate nursing intervention? a)contacting the physician b)increasing the rate of IV fluids c)reassessing vital signs in 15 minutes d)inserting a Foley catheter to monitor urine output

a)contacting the physician Explanation: The nurse should immediately contact the physician as these are concerning findings and may be indicative of serious critical events such as hypovolemic shock and hemorrhaging. Waiting to reassess the vital signs in 15 minutes can delay critical treatment, as would inserting a Foley catheter to monitor urine output.

A multigravida prenatal client with a history of postpartum depression tells the nurse that she is taking measures to make sure that she does not suffer that complication, including taking St. John's wort. What is the most important assessment for the nurse to make? a)current medications b)fetal growth c)liver functions d)mood status

a)current medications Explanation: St. John's wort, an herbal supplement commonly used to treat mild depression, interacts with many medications, making them less effective. If the client is already taking a prescription antidepressant, she can be at risk for serotonin syndrome. St. John's wort is not known to cause fetal growth or liver problems. It would be important to assess the client's mood after determining if the client is at risk for medication interactions.

A client with hypertrophic cardiomyopathy (HCM) is experiencing dyspnea, chest pain, syncope, fatigue, and palpitations and has an apical systolic thrill and heave, fourth heart sound (S4), and systolic murmur. Which nursing diagnosis should the nurse use to guide this client's care? a)decreased cardiac output b)risk for deficient fluid volume c)ineffective peripheral tissue perfusion d)risk for activity intolerance

a)decreased cardiac output Explanation: Decreased cardiac output is an appropriate nursing diagnosis for a client with HCM because the hypertrophied cardiac muscle decreases the effectiveness of the heart's contraction, decreasing cardiac output. Heart failure may complicate HCM, causing fluid volume excess; therefore, the nursing diagnosis of risk for deficient fluid volume is not applicable. Ineffective peripheral tissue perfusion would be applicable if the client is experiencing an alteration in peripheral pulses, capillary refill time greater than 3 seconds, or a change in skin characteristics. Although it might seem that the diagnosis of risk for activity intolerance would be applicable because of dyspnea and fatigue, addressing cardiac output will help reduce these symptoms.

On initial assessment of a 7-year-old child with rheumatic fever, which finding would require contacting the primary care provider immediately? a)heart rate of 150 bpm b)swollen and painful knee joints c)twitching in the extremities d)red rash on the trunk

a)heart rate of 150 bpm Explanation: A heart rate of 150 bpm is very high for a 7-year-old child and may indicate carditis. For this age group, the normal heart rate while awake is 70 to 110 bpm.Swollen and painful joints (e.g., the knee), twitching in the extremities (chorea), and a red rash on the trunk are characteristic findings in the child with rheumatic fever and do not require immediate primary care provider notification.

The comatose victim of a car accident is to have a gastric lavage. Which position would be most appropriate for the client during this procedure? a)lateral b)supine c)Trendelenburg's d)lithotomy

a)lateral Explanation: An unconscious client is best positioned in a lateral or semiprone position because these positions allow the jaw and tongue to fall forward, facilitate drainage of secretions, and prevent aspiration.Positioning the client supine carries a major risk of airway obstruction from the tongue, vomitus, or nasopharyngeal secretions.Trendelenburg's position, with the head lower than the heart, decreases effective lung volume and increases the risk of cerebral edema.The lithotomy position has no purpose in this situation.

The client with Ménière's disease is instructed to modify the diet. The nurse should explain that what is the most frequently recommended diet modification for Ménière's disease? a)low sodium b)high protein c)low carbohydrate d)low fat

a)low sodium Explanation: A low-sodium diet is frequently an effective mechanism for reducing the frequency and severity of the disease episodes. About three-quarters of clients with Ménière's disease respond to treatment with a low-salt diet. A diuretic may also be prescribed. Other dietary changes, such as high protein, low carbohydrate, and low fat, do not have an effect on Ménière's disease.

A client with toxic shock has been receiving ceftriaxone sodium, 1 g every 12 hours. In addition to culture and sensitivity studies, which other laboratory finding does the nurse monitor? a)serum creatinine b)spinal fluid analysis c)arterial blood gases d)serum osmolality

a)serum creatinine Explanation: The nurse monitors the blood levels of antibiotics, white blood cells, serum creatinine, and blood urea nitrogen because of the decreased perfusion to the kidneys, which are responsible for filtering out the ceftriaxone sodium. It is possible that the clearance of the antibiotic has been decreased enough to cause toxicity. Increased levels of these laboratory values should be reported to the health care provider (HCP) immediately. A spinal fluid analysis is done to examine cerebral spinal fluid, but there is no indication of central nervous system involvement in this case. Arterial blood gases are used to determine actual blood gas levels and assess acid-base balance. Serum osmolality is used to monitor fluid and electrolyte balance.

Which fetal presentation is most favorable for birth? a)vertex presentation b)transverse lie c)frank breech presentation d)posterior position of the fetal head

a)vertex presentation Explanation: Vertex presentation (flexion of the fetal head) is the optimal presentation for passage through the birth canal. Transverse lie presentation (when the neonate is in a horizontal position across the birth canal) requires a cesarean birth. Frank breech presentation, in which the buttocks present first, can make for a difficult vaginal delivery. Posterior positioning of the fetal head can make it difficult for the fetal head to pass under the maternal symphysis pubis bone.

A middle-aged male client comes to the clinic for an evaluation of difficulty urinating and nocturia. His father died from prostate cancer. He asks the nurse what he can do to ensure early detection of this disease. What question will the nurse ask next? a)"Do you perform monthly testicular self-examinations?" b)"Do you have a digital rectal examination and prostate-specific antigen tests yearly?" c)"Have you had a transrectal ultrasound within the last 10 years?" d)"How many times a night do you get up to void?"

b)"Do you have a digital rectal examination and prostate-specific antigen tests yearly?" Explanation: Prostate-specific antigen (PSA) and digital rectal examinations, although not specific for prostate cancer, will indicate possible changes in the prostate gland. The transrectal ultrasound would be performed as a follow-up for an increased PSA and/or an enlarged prostate gland. Testicular exams will not reveal changes in the prostate. The client already told the nurse he has nocturia, so this question is gathering more information about symptoms, not detection of the disease.

A client is admitted with an eating disorder. Which client response should the nurse address first? a)"My life is over if I gain weight." b)"I feel dizzy and light-headed when I get up." c)"I cannot eat because my teeth hurt." d)"I do not have the same energy that I used to have."

b)"I feel dizzy and light-headed when I get up." Explanation: The priority intervention, by the nurse, would be to assess the client's vital signs to note any alterations. A client stating "My life is over if I gain weight" is an example of catastrophizing. Dental erosion and caries are commonly found in a client with an eating disorder. Muscle weakness is also commonly found in a client with an eating disorder.

A client is admitted to the health care facility with abdominal pain, a low-grade fever, abdominal distention, and weight loss. Based on the diagnosis of acute pancreatitis the nurse will provide which explanation for the prescribed interventions? a)"I can offer you ibuprofen for pain with a small sip of water." b)"You are not allowed anything by mouth so that your pancreas can rest." c)"I will be starting antibiotic therapy once the blood cultures are obtained." d)"Activity is important, so you will be scheduled for physical therapy."

b)"You are not allowed anything by mouth so that your pancreas can rest." Explanation: The predominant clinical feature of acute pancreatitis is abdominal pain, which usually reaches peak intensity several hours after onset of the illness. Interventions include parenteral pain management preferably with an opioid, NPO status to decrease pancreatic activity, and bed rest to decrease body metabolism. Antibiotics are not usually indicated. The focus is on pain management and fluid replacement intraveneously. Because acute pancreatitis causes nausea and vomiting, the nurse should try to prevent fluid volume deficit, not overload. The nurse cannot help the client achieve adequate nutrition or understand the disease and its treatment until the client is comfortable and no longer in pain.

The nurse is assessing a client who has been in a car accident. The client reports sore ribs and painful breathing on the left side of the chest wall. A chest X-ray confirms fracture of two ribs and left-sided hemopneumothorax. What can the nurse anticipate? a)Aspirational thoracentesis will be performed to remove the accumulated bloody fluid. b)A chest tube will be inserted into the left pleural space and attached to a pleural evacuation device. c)Splinting of the affected ribs will be initiated and limitation of upper body activity recommended. d)Oxygen will be initiated and a bronchoscopy will be performed to identify the area of damage.

b)A chest tube will be inserted into the left pleural space and attached to a pleural evacuation device. Explanation: Shortness of breath and decreased breath sounds will be present if there is collapse of the lung because of loss of integrity of the pleural space. The chest tube will need to be inserted because of the rib fractures that have resulted in air and blood in the pleural space. The chest tubes will be removed when the hemopneumothorax has resolved. A thoracentesis will not be enough to resolve the hemopneumothorax; splinting of the ribs will not resolve the hemopneumothorax. Oxygen would be indicated, but a bronchoscopy will not confirm the area of damage if the lung is collapsed.

Upon initial assessment of a postoperative client, the nurse identifies that the I.V. infusion is different from the solution ordered by the physician. What is the first action the nurse should take? a)Discontinue the I.V. at the insertion site. b)Assess the client, call the physician, and then hang the ordered solution. c)Let the current IV. bag infuse while calling the physician to confirm the order. d)Replace the current I.V. with the ordered IV after the current I.V. finishes.

b)Assess the client, call the physician, and then hang the ordered solution Explanation: This scenario is the same as any medication error. The client must be assessed, the physician must be notified, and the correct solution should be given to the client. The other answers are incorrect because they do not ensure that the client will receive appropriate follow-up care for a medication error.

After extensive cardiac bypass surgery, a client returns to the intensive care unit on dobutamine, 5 mcg/kg/minute I.V. Which classification best describes dobutamine? a)Indirect-acting dual-active agent b)Direct-acting beta-active agent c)Indirect-acting beta-active agent d)Direct-acting alpha-active agent

b)Direct-acting beta-active agent Explanation: Adrenergic agents are classified according to their method of action and the type of receptor on which they act. Direct-acting agents act on the sympathetically innervated organ or tissue, whereas indirect-acting agents trigger the release of a neurotransmitter, usually norepinephrine. Dual-acting agents combine direct and indirect actions. Adrenergic agents act on alpha, beta, and dopamine receptors. Dobutamine acts directly on beta receptors. Thus, the drug can be described as a direct-acting beta-active agent.

A 10-week pregnant client tells the nurse she is worried about the fatigue that is causing difficulty with functioning at work. How can the nurse best instruct this client about the relief of fatigue? a)Explain that fatigue will improve during the second trimester. b)Instruct the client to take at least two rest breaks during the workday. c)Instruct the client to get at least 9 hours of sleep each night. d)Instruct the client to modify work hours during the first trimester.

b)Instruct the client to take at least two rest breaks during the workday. Explanation: Fatigue and frequent urination are early signs and symptoms of pregnancy that may continue through the first trimester. For the working pregnant client, it is advisable to take two 10- to 15-minute breaks within an 8-hour workday. While at home the client should nap or rest if she feels sleepy or tired. People need different amounts of sleep to help them feel rested. Telling the client to get 9 hours is a good suggestion, but it isn't helpful or practical if the client needs normally needs significantly more or less than that. In general, 7-8 hours is adequate. Modifying work hours can be suggested, but many times this is not something within the client's control. Fatigue will most likely improve during the second trimester, but that does not address the client's immediate concerns.

Which statement about a fetal biophysical profile would be incorporated into the teaching plan for a primigravid client with insulin-dependent diabetes? a)It determines fetal lung maturity. b)It is noninvasive using real-time ultrasound. c)It will correlate with the newborn's Apgar score. d)It requires the client to have an empty bladder.

b)It is noninvasive using real-time ultrasound. Explanation: The fetal biophysical profile, a noninvasive test using real-time ultrasound, assesses five parameters: fetal heart rate reactivity, fetal breathing movements, gross fetal body movements, fetal tone, and amniotic fluid volume. Fetal heart rate reactivity is determined by a nonstress test; the other four parameters are determined by ultrasound scanning. The results are available as soon as the test is completed and interpreted. The lecithin-sphingomyelin ratio is used to determine fetal lung maturity. Although the fetal biophysical profile is useful in predicting which fetuses may be at greater risk for compromise, there is no correlation with the newborn's Apgar score. The biophysical score is sometimes referred to as the fetal Apgar score. A score of 8 to 10 indicates fetal well-being. Use of an ultrasound requires the mother to have a full bladder.

The nurse is caring for a multigravid client and observes the woman squatting on the bed and the fetal head crowning. After calling for assistance and helping the client lie down, the nurse should perform which action next? a)Tell the client to push between contractions. b)Provide gentle support to the fetal head. c)Apply gentle upward traction on the neonate's anterior shoulder. d)Massage the perineum to stretch the perineal tissues.

b)Provide gentle support to the fetal head. Explanation: During a precipitous birth, after calling for assistance and helping the client lie down, the nurse should provide support to the fetal head to prevent too rapid of emergence leading to injury. It is not appropriate to tell the client to push between contractions because this may lead to lacerations. The shoulder should be delivered by applying downward traction until the anterior shoulder appears fully at the introitus, then upward pressure to lift out the other shoulder. Priority should be given to safe birth of the infant over protecting the perineum by massage.

A nurse is assisting with a circumcision. After the physician has started the procedure, the nurse reviews the neonate's medical record and notices that an informed consent form hasn't been signed. What should the nurse do? a)Continue assisting with the circumcision and ask the mother to sign the consent form after the procedure. b)Tell the physician to stop the procedure immediately because an informed consent form hasn't been signed. c)Inform the physician and ask the physician to quickly complete the procedure. d)Notify the medical director of the physician's negligence.

b)Tell the physician to stop the procedure immediately because an informed consent form hasn't been signed. Explanation: Parents have the legal right to decide whether their son is circumcised. The nurse and physician should always check the medical record for a signed informed consent form before beginning any procedure. It's unacceptable for the nurse to ask for consent after the procedure. Quickly completing the circumcision is also unacceptable because an informed consent form wasn't signed. Both the nurse and physician were negligent for not checking for a signed informed consent form.

Following an education session on proper hand hygiene, the nurse educator observes a nurse washing hands before entering a client's room. Which observation would alert the nurse educator to the need for further education? a)The nurse dries from finger tips down toward elbows. b)The nurse dries from forearms up toward fingers. c)The nurse keeps hands lower than elbows while washing. d)The nurse uses at least 3 to 5 mL of liquid soap.

b)The nurse dries from forearms up toward fingers. Explanation: Hand hygiene procedures involve drying from the fingers toward the forearm and discarding the paper towel. The other options should be included in hand hygiene practices.

A nurse hears a client state, "I've had it with this marriage. It would be so much easier to just hire someone to kill my husband!" What action should the nurse take? a)Since the client is still admitted to the hospital, the nurse must hold the statement in confidence. b)The nurse must start the process to warn the client's husband. c)An assessment of the client's response to treatment must be performed. d)The comment must be held in confidence because the client did not report the statement directly to the nurse.

b)The nurse must start the process to warn the client's husband. Explanation: Confidentiality must be broken if there are credible threats made against another person's safety. Confidentiality does not override the safety of other persons.

A client with acute bronchitis is admitted to the healthcare facility and is receiving supplemental oxygen via nasal cannula. When monitoring this client, the nurse suddenly hears a high-pitched whistling sound. What is the most likely cause of this sound? a)The water level in the humidifier reservoir is too low. b)The oxygen tubing is pinched. c)The client has a nasal obstruction. d)The oxygen concentration is above 44%.

b)The oxygen tubing is pinched. Explanation: Pinching of the tubing used to deliver oxygen causes a high-pitched whistling sound. When the water level in the humidifier reservoir is too low, the oxygen tubing appears dry but doesn't make noise. A client with a nasal obstruction becomes more uncomfortable with nasal prongs in place and doesn't experience relief from oxygen therapy; the client's complaints, not an abnormal sound, would alert the nurse to this problem. A nasal cannula can't deliver oxygen concentrations above 44%.

A nurse is instructing an unlicensed assistive personnel (UAP) on the proper care of a client in Buck's extension traction following a fracture of the left fibula. Which observation would indicate that teaching has been effective? a)The leg in traction is kept externally rotated. b)The weights are allowed to hang freely over the end of the bed. c)The UAP instructs the client to perform ankle rotation exercises. d)The UAP lifts the weights while assisting the client as he moves up in bed.

b)The weights are allowed to hang freely over the end of the bed. Explanation: In Buck's traction, the weights should hang freely without touching the bed or floor. Lifting the weights would break the traction. The client should be moved up in bed, allowing the weight to move freely along with the client. The leg should be kept in straight alignment. Performing ankle rotation exercises could cause the leg to go out of alignment.

A client with obsessive-compulsive disorder, who was admitted early yesterday morning, must make his bed 22 times before he can have breakfast. Because of his behavior, the client missed having breakfast yesterday with the other clients. Which action should the nurse institute to help the client be on time for breakfast? a)Tell the client to make his bed one time only. b)Wake the client an hour earlier to perform his ritual. c)Insist that the client stop his activity when it is time for breakfast. d)Advise the client to have breakfast first before making his bed

b)Wake the client an hour earlier to perform his ritual. Explanation: The nurse should wake the client an hour earlier to perform his ritual so that he can be on time for breakfast with the other clients. The nurse provides the client with time needed to perform rituals because the client needs to keep his anxiety in check. The nurse should never take away a ritual, because panic will ensue. The nurse should work with the client later to slowly set limits on the frequency of the action.

The nurse determines that a client has an antenatal or intrapartum risk score of 2. Based on this information, which activity level should the nurse recommend to the client during labor? a)bathroom privileges only b)ambulate as tolerated c)up in the chair at the side of the bed d)complete bed rest with IV hydration

b)ambulate as tolerated Explanation: The client has a low risk score (0-2) and therefore should be encouraged to ambulate as desired during labor and birth. Bathroom privileges only or complete bed rest imply that the client should be in bed for the majority of the laboring process which is contradictory to associated health promotion practices during the labor process for a client with a low risk score.

A 2-month-old infant is at risk for an ileus after surgery to correct intussusception. What should be included in a focused assessment for this complication? Select all that apply. a)measurement of urine specific gravity b)assessment of bowel sounds c)characteristics of the first stool d)measurement of gastric output e)bilirubin levels

b)assessment of bowel sounds c)characteristics of the first stool d)measurement of gastric output Explanation: A postoperative ileus is a functional obstruction of the bowel. Assessment of bowel sounds, the first stool, and the amount of gastric output provide information about the return of gastric function. Measurement of urine specific gravity provides information about fluid and electrolyte status; bilirubin levels provide information about liver function, and neither of these tests need to be included in a focused assessment for ileus.

In discussing home care with a client after transurethral resection of the prostate (TURP), what should the nurse tell the male client about dribbling of urine after this surgery? Dribbling of urine: a)can be a chronic problem. b)can persist for several months. c)is an abnormal sign that requires intervention. d)is a sign of healing within the prostate.

b)can persist for several months Explanation: Dribbling of urine can occur for several months after TURP. The client should be informed that this is expected and is not an abnormal sign. The nurse should teach the client perineal exercises to strengthen sphincter tone. The client may need to use pads for temporary incontinence. The client should be reassured that continence will return in a few months and will not be a chronic problem. Dribbling is not a sign of healing, but is related to the trauma of surgery.

Which measure is contraindicated when the nurse assists a child who has leukemia with oral hygiene? a)applying petroleum jelly to the lips b)cleaning the teeth with a toothbrush c)swabbing the mouth with moistened cotton swabs d)rinsing the mouth with a nonirritating mouthwash

b)cleaning the teeth with a toothbrush Explanation: The oral mucous membranes are easily damaged and are commonly ulcerated in the client with leukemia. It is better to provide oral hygiene without using a toothbrush, which can easily damage sensitive oral mucosa. Applying petroleum jelly to the lips, swabbing the mouth with moistened cotton swabs, and rinsing the mouth with a nonirritating mouthwash are appropriate oral care measures for a child with leukemia.

A client is being admitted to the substance abuse unit for alcohol detoxification. As part of the intake interview, a nurse asks when the client had the last alcoholic drink. The client says that the last drink was 6 hours before admission. Based on this response, the nurse should expect early withdrawal symptoms to peak: a)immediately. b)in 1 to 2 days. c)within 2 to 7 days. d)after 7 days.

b)in 1 to 2 days. Explanation: Acute withdrawal symptoms from alcohol may begin 6 hours after the client has stopped drinking and peak 1 to 2 days later. Alcohol withdrawal delirium may occur 2 to 4 days — even up to 7 days — after the last drink.

After a lengthy labor, a primigravid client gives birth to a healthy newborn boy with a moderate amount of skull molding. What information would the nurse include when explaining to the parents about this condition? a)It is typically seen with breech births. b)It usually lasts a day or two before resolving. c)It is unusual when the brow is the presenting part. d)Surgical intervention may be necessary to alleviate pressure.

b)it usually lasts a day or two before resolving Explanation: Molding occurs with vaginal births and is commonly seen in newborns. This is especially true with primigravid clients experiencing a lengthy labor process. Parents need to be reassured that it is not permanent and that it typically lasts a day or two before resolving. Molding rarely is present if the fetus is in a breech or brow presentation. Surgical intervention is not necessary.

A nurse is assessing a client with nephrotic syndrome. The nurse should assess the client for which condition? a)hematuria b)massive proteinuria c)increased serum albumin level d)weight loss

b)massive proteinuria Explanation: Nephrotic syndrome is characterized by massive proteinuria caused by increased glomerular membrane permeability. Other symptoms include peripheral edema, hyperlipidemia, and hypoalbuminemia. Because of the edema, clients retain fluid and may gain weight. Hematuria is not a symptom related to nephrotic syndrome.

A nurse is preparing to administer a unit of blood to a client with anemia. After its removal from the refrigerator, the blood should be administered within: a)1 hour. b)2 hours. c)4 hours. d)6 hours.

c)4 hours. Explanation: Refrigeration delays the growth of bacteria in the blood. After the blood is removed from the refrigerator, it must be administered within 4 hours. If the blood is administered too rapidly, within 1 or 2 hours, the client could experience fluid overload. Six hours is too long because the extended time out of refrigeration increases the risk of contamination and growth of bacteria.

The health care provider (HCP) who elects to perform a cesarean birth on a primigravid client for fetal distress has informed the client of possible risks during the procedure. When the nurse asks the client to sign the consent form, the client's husband says, "I will sign it for her. She is too upset by what is happening to make this decision." What should the nurse do? a)Ask the client if this is acceptable to her. b)Have the client and her husband both sign the consent form. c)Ask the client to sign the consent form. d)Ask the HCP to witness the consent form.

c)Ask the client to sign the consent form. Explanation: Preparation for cesarean birth is similar to preparation for any abdominal surgery. The client must give informed consent. Another person may not sign for the client unless the client is unable to sign the form. If this is the case, only certain designated people can do so legally. The husband does not need to sign the form unless his wife is unable to do so. In an emergency, surgery may be performed without a written consent if it is done to save the life of the mother or the child, or both.

A nurse is caring for an elderly bedridden adult in the long term care facility. To prevent pressure ulcers, which intervention should the nurse include in the care plan? a)Turn and reposition the client every 4 hours. b)Massage lotion over bony prominences when turning. c)Develop a written, individual turning schedule. d)Use two people when sliding the client up in bed.

c)Develop a written, individual turning schedule. Explanation: A turning schedule sheet helps ensure that the client gets turned and, thus, helps prevent pressure ulcers. Turning should occur every 1 to 2 hours — not every 4 hours — for clients who are in bed for prolonged periods. The nurse should apply lotion to keep the skin moist, but should avoid vigorous massage, which could damage capillaries. When moving the client, the nurse should lift — rather than slide — the client to avoid shearing, despite the amount of helpers.

Which sound should the nurse expect to hear when percussing a distended bladder? a)Hyperresonance. b)Tympany. c)Dullness. d)Flatness.

c)Dullness. Explanation: A distended bladder produces dullness when percussed because of the presence of urine. Hyperresonance is a percussion sound that is present in hyperinflated lungs. Tympany, a loud drumlike sound, occurs over gas-filled areas such as the intestines. Flat sounds occur over very dense tissue that has no air present.

A client with venous insufficiency reports swelling in the feet and ankles. What is the most appropriate intervention for the nurse to recommend? a)Limit fluid intake after 8 pm. b)Buy well-fitting walking shoes. c)Elevate the feet several times a day. d)Wear a pair of knee-high support hose.

c)Elevate the feet several times a day. Explanation: Elevating the feet will promote venous return and decrease foot and ankle edema. Limiting fluid intake is not recommended unless there are additional medical complications such as heart failure; limiting fluids after 8 pm can help with nocturia but time is irrelevant to edema prevention. Buying walking shoes will not necessarily decrease edema. Over-the-counter knee-high "support hose" are not the same as medical-grade graduated compression stockings, and there are some contraindications to compression that should first be ruled out. Therefore, the nurse should not recommend this intervention unless the elevation of legs fails to solve the edema, at which time the client should consult the health care provider about the use of medically approved compression stockings.

A nurse should perform which intervention for a client with Cushing's syndrome? a)Offer clothing or bedding that's cool and comfortable. b)Suggest a high-carbohydrate, low-protein diet. c)Explain that the client's physical changes are a result of excessive corticosteroids. d)Explain the rationale for increasing salt and fluid intake in times of illness, increased stress, and very hot weather.

c)Explain that the client's physical changes are a result of excessive corticosteroids. Explanation: The nurse should explain to the client that Cushing's syndrome causes physical changes related to excessive corticosteroids. Clients with hyperthyroidism, not Cushing's syndrome, are heat intolerant and must have cool clothing and bedding. Clients with Cushing's syndrome should have a high-protein, not low-protein, diet. Clients with Addison's disease must increase sodium intake and fluid intake in times of stress of prevent hypotension.

A client has just been transferred to the postanesthesia recovery room following a laparotomy. In addition to vital signs, what are the most important initial assessments that need to be completed? a)Skin color, warmth of extremities, and mental status assessment b)Metabolic rate, orientation, and presence of reflexes c)Level of consciousness, pain level, and wound dressing d)Emotional status, response to anesthesia, and social support systems

c)Level of consciousness, pain level, and wound dressing Explanation: Postoperatively vital signs are taken to ensure that vital systems are returning to normal after anesthesia. It is also important to check the level of consciousness, particularly postanesthesia and postanalgesia. Pain levels need to be monitored. Dressings need to be checked to detect abnormal increase in bleeding. The nurse would not check metabolic rate and reflexes, emotional response, or social support systems as an initial assessment after surgery.

Two weeks after being diagnosed with a streptococcal infection, a client develops fatigue, a low-grade fever, and shortness of breath. The nurse auscultates bilateral crackles and observes jugular vein distention. Urinalysis reveals red and white blood cells and protein. After the physician diagnoses poststreptococcal glomerulonephritis, the client is admitted to the medical-surgical unit. Which immediate action should the nurse take? a)Encourage activity as tolerated. b)Provide a high-protein, fluid-monitored diet. c)Monitor patient blood pressure. d)Place the client on a sheepskin, and monitor for increasing edema.

c)Monitor patient blood pressure. Explanation: Blood pressure control is a priority assessment in clients with poststreptococcal glomerulonephritis. The blood pressure can be increased for up to 6 weeks after treatment. The nurse must provide a low-protein diet during the acute phase. The nurse must also closely monitor the client's fluid intake and output. Clients should be placed on bed rest to control hypertension and workload on the kidney. Although providing comfort measures (such as placing the client on a sheepskin) are important, this action isn't a priority.

A nurse is assisting a grieving client and spouse to deal with the loss of their 24-week-old infant. Which of the following actions would be most appropriate from the nurse? Select all that apply. a)The nurse should control emotions so as to not upset the parents. b)Remind the parents that there must have been something wrong with the baby. c)Provide an early opportunity for the couple to see the child if desired. d)Offer to stay with the grieving parents. e)Answer the parents' questions accurately.

c)Provide an early opportunity for the couple to see the child if desired. d)Offer to stay with the grieving parents. e)Answer the parents' questions accurately. Explanation: Seeing the fetus/baby helps parents face the reality of the loss, reduces painful fantasies, and offers an opportunity for closure. Wishes of the parents should be respected either way. Not showing any emotion in front of the parents may not let the parents know that the nurse has also been affected by the loss. Trying to provide a reason for the death of the baby tends to invoke anger in parents who wonder what the reason was and why it had to be them. Some parents are quite anxious about being left alone with the baby and prefer not to have the nurse leave the room. Allowing the parents to ask questions and answering accurately will help the grieving parents understand their loss at their pace.

What is the most important nursing intervention when caring for a child with a newly applied wet hip spica cast? a)Use the abductor bar to help move the child. b)Cover the cast in plastic to keep it clean. c)Reposition the child every 1 to 2 hours. d)Use the fingertips when handling the cast.

c)Reposition the child every 1 to 2 hours. Explanation: The child in a wet hip spica cast should be turned every 1 to 2 hours to help dry all sides of the cast and prevent skin breakdown. The abductor bar shouldn't be used for turning the child, even after the cast is dry. A wet cast shouldn't be covered with plastic because this will impede drying, reduce air circulation, and allow heat to build up in the cast. A wet cast should be handled using the palms, because fingertips may cause indentations and pressure points.

A client is taking aluminum hydroxide tablets along with sucralfate daily 1 hour before meals. The nurse should teach the client which of the following? a)Sucralfate should be taken every 4 hours to be effective. b)Aluminum hydroxide and sucralfate should not be taken together. c)Sucralfate should be taken on an empty stomach 1 hour before meals. d)Sucralfate and aluminum hydroxide should be taken early in the morning.

c)Sucralfate should be taken on an empty stomach 1 hour before meals. Explanation: Sucralfate is taken on an empty stomach at least 1 hour before meals and at bedtime to allow a protective coating to form over the ulcer before high levels of gastric acidity occur. It is not to be taken every 4 hours. Aluminum hydroxide and sucralfate are effective when prescribed together. Aluminum hydroxide should be taken for 2 hours before or after taking sucralfate, not at the same time.

One day after cataract surgery, the client is having discomfort from bright light. What should the nurse advise the client to do? a)Dim lights in the house and stay inside for one week. b)Attach sun shields to existing eyeglasses when in direct sunlight. c)Use sunglasses that wrap around the side of the face when in bright light. d)Patch the affected eye when in bright light.

c)Use sunglasses that wrap around the side of the face when in bright light. Explanation: To prevent discomfort from bright light the client should wear sunglasses that cover the front and side of the face, thus minimizing light that comes into the eye from any direction. It is not necessary to remain in dim light or inside. Attaching sun shields or sunglasses to existing glasses will not cover the eye sufficiently, and bright light will come in on the side of the face. It is not necessary to patch the affected eye.

A nurse is caring for a group of clients on a medical-surgical floor. Which client is at greatest risk for developing pneumonia? a)a client with a history of smoking two packs of cigarettes per day until quitting 2 years ago b)a client who ambulates in the hallway daily c)a client with a nasogastric tube d)a client who has an order for acetaminophen with codeine for pain but has not requested it

c)a client with a nasogastric tube Explanation: Nasogastric, orogastric, and endotracheal tubes increase the risk of pneumonia because of the risk of aspiration from improperly placed tubes. Frequent oral hygiene and checking tube placement help prevent aspiration and pneumonia. Although a client who smokes is at increased risk for pneumonia, the risk decreases if the client has stopped smoking. Ambulation helps prevent pneumonia. A client who receives opioids, not acetaminophen, has a risk of developing pneumonia because respiratory depression may occur.

A nurse caring for a preterm neonate knows that positioning can benefit high-risk neonates. Which position is appropriate for a preterm neonate? a)hyperabduction and extension of the arms with external rotation of the hips b)neck extension and back arching with flattened shoulders c)adduction and flexion of the extremities with gently rounded shoulders d)abduction and flexion of the arms with flattened shoulders

c)adduction and flexion of the extremities with gently rounded shoulders Explanation: The goal of neonatal positioning is to gently round shoulders and flex elbows and to avoid abduction of the shoulders and hips. This positioning enhances physiologic stability and developmental progress. Hyperabduction and external rotation in a preterm neonate may result in contractures. Neck extension, back arching, flattened shoulders, and abduction should be avoided in neonates.

During the first 24 hours after a client is diagnosed with addisonian crisis, which intervention should the nurse perform frequently? a)weigh the client. b)test urine for ketones. c)assess vital signs. d)administer oral hydrocortisone.

c)assess vital signs. Explanation: Because the client in addisonian crisis is unstable, vital signs and fluid and electrolyte balance should be assessed every 30 minutes until the client is stable. Daily weights are sufficient when assessing the client's condition. The client shouldn't have ketones in their urine, so there is no need to assess the urine for their presence. Oral hydrocortisone isn't administered during the first 24 hours in severe adrenal insufficiency.

A client enters the crisis unit complaining of increased stress from studies as a medical student. The client reports increasing anxiety for the past month. The physician orders alprazolam, 0.25 mg by mouth three times per day, along with professional counseling. Before administering alprazolam, the nurse reviews the client's medication history. Which drug can produce additive effects when taken concomitantly with alprazolam? a)levodopa b)famotidine c)diphenhydramine d)norgestrel

c)diphenhydramine Explanation: Using benzodiazepines with other central nervous system depressants such as diphenhydramine produces additive effects. Alprazolam doesn't cause clinically significant drug interactions with levodopa, famotidine, or hormonal contraceptives such as norgestrel.

A client who has a history of Crohn's disease is admitted to the hospital with fever, diarrhea, cramping, abdominal pain, and weight loss. The nurse should review the client's laboratory reports to determine which potential complication of the client's symptoms? a)hyperalbuminemia b)thrombocytopenia c)hypokalemia d)hypercalcemia

c)hypokalemia Explanation: Hypokalemia is the most expected laboratory finding owing to the diarrhea. Hypoalbuminemia can also occur in Crohn's disease; however, the client's potassium level is of greater importance at this time because a low potassium level can cause cardiac arrest. Anemia is an expected development, but thrombocytopenia is not. Calcium levels are not affected.

The client who experiences angina has been told to follow a low-cholesterol diet. Which meal would be best? a)hamburger, salad, and milkshake b)baked liver, green beans, and coffee c)spaghetti with tomato sauce, salad, and coffee d)fried chicken, green beans, and skim milk

c)spaghetti with tomato sauce, salad, and coffee Pasta, tomato sauce, salad, and coffee would be the best selection for the client following a low-cholesterol diet. Hamburgers, milkshakes, liver, and fried foods tend to be high in cholesterol.

Which action should the nurse do first when noting clear drainage on the child's dressing and bed linen after a craniotomy for a brain tumor? a)Change the dressing. b)Elevate the head of the bed. c)Test the fluid for glucose. d)Notify the health care provider (HCP).

c)test the fluid for glucose Explanation: Glucose in this clear, colorless fluid indicates the presence of cerebrospinal fluid. Excessive fluid leakage should be reported to the HCP. The nurse should not change the dressing of a postoperative craniotomy client unless instructed to do so by the surgeon. Ordinarily, the head of the bed would not be elevated because this would put pressure on the sutures. The nurse should notify the HCP after testing the fluid for glucose.

A client reports having a dry, hacking cough that disturbs sleep at night. Which antitussive agent and intervention are most appropriate for this client? a)decreasing the room temperature and b)administering a benzonatate increasing fluids to liquefy secretions and administering codeine c)using a cooling mist humidifer and administering dextromethorphan d)providing a heat vaporizer and administering hydrocodone

c)using a cooling mist humidifer and administering dextromethorphan Explanation: Dextromethorphan is the most widely used antitussive in Canada because it produces few adverse reactions while effectively suppressing a cough. A cool mist humidifier will help open nasal passages. Benzonatate is used for cough associated with respiratory conditions and chronic pulmonary diseases. Opioid antitussives, such as codeine and hydrocodone, are reserved for treating unruly coughs usually associated with lung cancer.

The mother of a client who has a radium implant asks why so many nurses are involved in her daughter's care. She states, "The doctor said I can be in the room for up to 2 hours each day, but the nurses say they are restricted to being here for 30 minutes." What should the nurse explain to the client? a)touch the client, which increases their exposure to radiation. b)work with many clients and could carry infection to a client receiving radiation therapy, if exposure is prolonged. c)work with radiation on an ongoing basis, while visitors have infrequent exposure to radiation. d)are at greater risk from the radiation because they are younger than the mother.

c)work with radiation on an ongoing basis, while visitors have infrequent exposure to radiation Explanation: The three factors related to radiation safety are time, distance, and shielding. Nurses on radiation oncology units work with radiation frequently and so must limit their contact. Nurses are physically closer to clients than are visitors, who are often asked to sit 6 feet (182.9 cm) away from the client. Touching the client does not increase the amount of radiation exposure. Aseptic technique and isolation prevent the spread of infection. Age is a risk factor for people in their reproductive years.

A client admitted in an acute psychotic state hears terrible voices in the head and thinks a neighbor is upset with the client. What is the nurse's best response? a)"What has your neighbor been doing that bothers you?" b)"How long have you been hearing these terrible voices?" c)"We won't let your neighbor visit, so you'll be safe." d)"What exactly are these terrible voices saying to you?"

d)"What exactly are these terrible voices saying to you?" Explanation: The nurse needs to collect additional information about the client's report about hearing voices. Assessing the content of hallucinations is essential to determine whether they are command hallucinations that the client might act on. Asking about what the neighbor has been doing or telling the client that the neighbor will not visit indirectly reinforces the delusion about the neighbor. Although determining the onset and duration of the voices is important, the nurse needs to assess the content of the hallucinations first.

The nurse is irrigating a client's ear due to impacted cerumen. Which nursing action is correct for this procedure? a)The nurse should push fluid forcefully into the ear to remove the cerumen. b)The nurse should use cool water with the irrigation for client comfort. c)The nurse should irrigate as a last resort after trying to mechanically remove the cerumen. d)The nurse should instill mineral oil 30 minutes before irrigation to soften the cerumen.

d)The nurse should instill mineral oil 30 minutes before irrigation to soften the cerumen. Explanation: The nurse can use mineral oil to soften the cerumen before irrigation of the ear. Using warm water, not cool water, is best for irrigation for client comfort and loosening of the cerumen. The client would need gentle, not forceful, irrigation in order to prevent perforation of the tympanic membrane. Irrigation would be completed before attempting to mechanically remove the cerumen.

The registered nurse (RN) is referred to a client's home when spouses have been confirmed to have scabies. The family asks, "How will we get rid of this?" When instructing on the proper procedure to wash contaminated clothing and sheets, which nursing instruction is a priority? a)Use commercial grade laundry detergent. b)Pretreat clothing where scabies contact existed. c)Wash clothes through two laundry cycles. d)Use hot water throughout wash cycle.

d)Use hot water throughout wash cycle. Explanation: The nurse instructs to use hot water throughout the wash cycle. Using hot water kills scabies and infectious agents on the laundry. If using the correct wash settings, the client does not need to use commercial grade laundry detergent and the clothing does not need pretreated or washed through two cycles. The family would also be instructed to dry the articles in a dryer. The family would clean all belongings thoroughly due to the ease of transmission.

Which facility would the nurse rank as the lowest priority to expand when developing a community-based service program for clients with chronic mental illnesses? a)partial hospitalization programs b)psychiatric home care c)residential services d)long-term hospitals

d)long-term hospitals Explanation: For a community-based program, the need for long-term hospitalization is least needed if the other services, such as partial hospitalization programs, psychiatric home care, and residential services, are available and accessible.

A nurse who is preparing to boost a client up in bed instructs the client to use the overbed trapeze. Which risk factor for pressure ulcer development is the nurse reducing by instructing the client to move in this manner? a)friction b)impaired circulation c)localized pressure d)shearing forces

d)shearing forces Explanation: Friction, impaired circulation, localized pressure, and shearing forces are all risk factors of pressure ulcer development; trapeze use reduces shearing forces. Shearing forces (opposing forces that cause layers of skin to move over each other, stretching and tearing capillaries and, eventually, resulting in necrosis) can occur as clients slide down in bed or are pulled up in bed. Subcutaneous skin layers adhere to the sheets while deeper layers, muscle, and bone slide in the direction of movement. To reduce shearing forces, the nurse should instruct the client to use an overbed trapeze, place a draw sheet under the client to move him up in bed, and keep the head of the bed no higher than 30 degrees.